Safety culture to improve accidental events reporting in radiotherapy.

Background and purpose. The potential for unintended and adverse radiation exposure in radiotherapy is real and should be studied because radiotherapy is a highly complex, multistep process which requires input from numerous individuals from different areas and steps of the radiotherapy workflow. The 'Incident' (I) is a consequence of which are not negligible from the point of view of protection or safety. A 'near miss' (NM) is defined as an event which is highly likely to happen but did not occur. The purpose of this work is to show that through a systematic reporting and analysis of these adverse events, their occurrence can be reduced. Materials and methods. Staff were trained to report every type of unintended and adverse radiation exposure and to provide a full description of it. Results. By 2018, 110 worksheets had been collected, with an average of 6.1 adverse events per year (with 780 patients treated per year, meaning an average incident rate of 0.78%). In 2001–2009, 37 events were registered (13 I and 24 NM) the majority of them in the decision phase (12/37), while in 2010–2013, 42 (1 I and 41 NM) in both the dose-calculation and transfer phase (19/42). In 2014–2018, 31 events (1 I and 30 NM) were equally distributed across the phases of the radiotherapy process. In 9/15 cases of I the procedure were corrected. Conclusion. The complexity of the radiotherapy workflow is prone to errors, and this must be taken into account. Incident reporting is a very useful technique for reducing the errors through the timely modification of the involved procedures.